Enhanced coordination of care to reduce medication risks in older home care clients in primary care: a randomized controlled trial.

BACKGROUND: As populations are aging, a growing number of home care clients are frail and use multiple, complex medications. Combined with the lack of coordination of care this may pose uncontrolled polypharmacy and potential patient safety risks. The aim of this study was to assess the impact of a care coordination intervention on medication risks identified in drug regimens of older home care clients over a one-year period. METHODS: Two-arm, parallel, cluster randomized controlled trial with baseline and follow-up assessment at 12 months. The study was conducted in Primary Care in Lohja, Finland: all 5 home care units, the public healthcare center, and a private community pharmacy. PARTICIPANTS: All consented home care clients aged > 65 years, using at least one prescription medicine who were assessed at baseline and at 12 months. INTERVENTION: Practical nurses were trained to make the preliminary medication risk assessment during home visits and report findings to the coordinating pharmacist. The coordinating pharmacist prepared the cases for the triage meeting with the physician and home care nurse to decide on further actions. Each patient's physician made the final decisions on medication changes needed. Outcomes were measured as changes in medication risks: use of potentially inappropriate medications and psychotropics; anticholinergic and serotonergic load; drug-drug interactions. RESULTS: Participants (n = 129) characteristics: mean age 82.8 years, female 69.8%, mean number of prescription medicines in use 13.1. The intervention did not show an impact on the medication risks between the original intervention group and the control group in the intention to treat analysis, but the per protocol analysis indicated tendency for effectiveness, particularly in optimizing central nervous system medication use. Half (50.0%) of the participants with a potential need for medication changes, agreed on in the triage meeting, had none of the medication changes actually implemented. CONCLUSION: The care coordination intervention used in this study indicated tendency for effectiveness when implemented as planned. Even though the outcome of the intervention was not optimal, the value of this paper is in discussing the real world experiences and challenges of implementing new practices in home care. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02545257). Registered September 9 2015.

Coordinating resources for prospective medication risk management of older home care clients in primary care: procedure development and RCT study design for demonstrating its effectiveness.

BACKGROUND: The magnitude of safety risks related to medications of the older adults has been evidenced by numerous studies, but less is known of how to manage and prevent these risks in different health care settings. The aim of this study was to coordinate resources for prospective medication risk management of home care clients ≥ 65 years in primary care and to develop a study design for demonstrating effectiveness of the procedure. METHODS: Health care units involved in the study are from primary care in Lohja, Southern Finland: home care (191 consented clients), the public healthcare center, and a private community pharmacy. System based risk management theory and action research method was applied to construct the collaborative procedure utilizing each profession's existing resources in medication risk management of older home care clients. An inventory of clinical measures in usual clinical practice and systematic review of rigorous study designs was utilized in effectiveness study design. DISCUSSION: The new coordinated medication management model (CoMM) has the following 5 stages: 1) practical nurses are trained to identify clinically significant drug-related problems (DRPs) during home visits and report those to the clinical pharmacist. Clinical pharmacist prepares the cases for 2) an interprofessional triage meeting (50-70 cases/meeting of 2 h) where decisions are made on further action, e.g., more detailed medication reviews, 3) community pharmacists conduct necessary medication reviews and each patients' physician makes final decisions on medication changes needed. The final stages concern 4) implementation and 5) follow-up of medication changes. Randomized controlled trial (RCT) was developed to demonstrate the effectiveness of the procedure. The developed procedure is feasible for screening and reviewing medications of a high number of older home care clients to identify clients with severe DRPs and provide interventions to solve them utilizing existing primary care resources. TRIAL REGISTRATION: The study is registered in the Clinical Trials.gov ( NCT02545257 ). Registration date September 9 2015.

Successful Eradication of Multidrug Resistant Acinetobacter in the Helsinki Burn Centre.

Multidrug-resistant (MDR) Acinetobacter is an important pathogen implicated in nosocomial infections in healthcare environments. Virulence factors, resistance mechanisms, and limited therapeutic options make this pathogen a major problem currently facing burn intensive care units (ICUs) worldwide. The purpose of this study was to assess the effect of infection control measures taken in Helsinki Burn Centre in 2001 on MDR Acinetobacter prevalence in ICU burn patients. Data were retrospectively collected from patient files from 1998 to 2012. ICU burn patients were defined as those with either over 30% of total body surface area burnt or requiring mechanical ventilation. Inclusion criteria consisted of patients who tested positive for Acinetobacter sp. in routine bacterial cultures or cultures taken because of a clinically suspected infection. Infection control interventions performed in 2001 consisted of various shower room renovations and changes in hospital hygiene and burn treatment regimes. Between 1998 and 2012, 75 patients were diagnosed with Acinetobacter sp. colonization. Following the infection control interventions the incidence of Acinetobacter sp. radically declined. Between 1998 and 2001, there were 31 cases of MDR Acinetobacter colonizations diagnosed, but from 2002 to 2012 no MDR strains were found. Changes to hospital hygiene and wound treatment protocols as well as structural changes to the hospital environment can have a major impact on preventing and treating Acinetobacter outbreaks in burn centers.